Alcoholism. Alcohol Misuse and Dependence
Although it is impossible to define alcoholism precisely, among the commonly used screening instruments for this disorder are the CAGE questionnaire, short Michigan Alcoholism Screening Test (SMAST), National Council on Alcoholism criteria, and DSM-III-A criteria. Although not generally included under the topic alcoholism, hazardous or at-risk drinking should also be considered. For men, at-risk drinking is defined as greater than 14 drinks/week or more than 4 drinks/occasion. For women, at-risk drinking is defined as about half that given for men.
Alcohol Misuse and Dependence
A wide range of physical, social and psychiatric problems are associated with excessive drinking. Alcohol misuse occurs when a patient is drinking in a way that regularly causes problems to the patient or others.
The problem drinker is one who causes or experiences physical, psychological and/or social harm as a consequence of drinking alcohol. Many problem drinkers, while heavy drinkers, are not physically addicted to alcohol.
Heavy drinkers are those who drink significantly more in terms of quantity and/or frequency than is safe to do so long term.
Binge drinkers are those who drink excessively in short bouts, usually 24-48 hours long, separated by often quite lengthy periods of abstinence. Their overall monthly or weekly alcohol intake may be relatively modest.
Alcohol dependence is defined by a physical dependence on or addiction to alcohol. The term ‘alcoholism’ is a confusing one with off-putting connotations of vagrancy, ‘meths’ drinking and social disintegration. It has been replaced by the term ‘alcohol dependence syndrome’.
Alcohol dependence syndrome
Dependence is a pattern of repeated self-administration that usually results in tolerance, withdrawal and compulsive drugtaking behaviour, the essential element of which is the continued use of the substance despite significant substance-related problems. Figure 2.5 outlines the main characteristics of the syndrome but these do not necessarily present in any particular order. Symptoms of alcohol dependence in a typical order of occurrence are shown in Table 2.17. Diagnostic criteria for alcohol withdrawal syndrome are shown in Table 2.18.
Fig. 2.5 Elements of the alcohol dependence syndrome.
Alcoholism. Alcohol Misuse and Dependence
EPIDEMIOLOGY & DEMOGRAPHICS
Epidemiology of alcohol misuse
Twenty per cent of men and 10% of women drink more than double the recommended limits of 3 units a day of alcohol for men and 2 units for women in the UK. Some 4% of men and 2% of women report alcohol withdrawal symptoms, suggesting dependence. Approximately one in five male admissions to acute medical wards is directly or indirectly due to alcohol. Between 33% and 40% of accident and emergency attenders have blood alcohol concentrations above the present UK legal limit for driving. People with serious drinking problems have a two to three times increased risk of dying compared to members of the general population of the same age and sex.
INCIDENCE (IN U.S.):
• 20% achieve abstinence without help, 70% achieve sobriety for 1 yr.
PREVALENCE (IN U.S.): 7% of population 18 yr or older
• Lifetime risk for males 8% to 10%
• Lifetime risk for females 3% to 5%
PEAK INCIDENCE: 20 to 40 yr
GENETICS: More common with a family history of alcoholism and in patients of Irish, Scandinavian, and Native American descent
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Recurring minor trauma
• GI bleeding
• Liver disease
• Odor of alcohol on breath
• Peripheral neuropathy
• Recent memory loss
• Table 1-7 describes some alcohol-related medical disorders.
|AFFECTED ORGAN OR SYSTEM
||TABLE 1-7 -- Alcohol-Related Medical Disorders
||Deficiencies of primarily thiamine but also the following:
Vitamins: Folate, thiamine, pyridoxine, niacin, riboflavin
Minerals: Magnesium, zinc, calcium
|Metabolites and electrolytes
||Hypoglycemia, ketoacidosis, hyperlipidemia, hyperuricemia, hypomagnesemia, hypophosphatemia
||Liver: Fatty liver, hepatitis, cirrhosis
Gut: Esophagitis, gastritis
||Brain: Hepatic encephalopathy, Wernicke-Korsakoff syndrome, cerebellar degeneration, central pontine myelinolysis,
Marchiafava-Bignami disease, cerebral atrophy with dementia
Neuromuscular: Neuropathy, myopathy
||Heart: Arrhythmia, cardiomyopathy
||Macrocytosis, anemia, thrombocytopenia, leukopenia
||Pseudo-Cushing’s syndrome, testicular atrophy, amenorrhea
Fetal alcohol syndrome
• Social and genetic factors important
• Risk factors:
1. Broken homes
4. Recurrent depression
5. Addiction to another substance, including tobacco
• Screening tests (CAGE or SMAST)
• Blood studies
• Stool for occult blood
• Aspartate aminotransferase (SGOT, AST)
• Mean corpuscular volume (MCV)
Indicated only if there is a history of trauma
• Depression, if present, should be treated at same time ETOH is withdrawn.
Psychological treatment of problem drinking
Successful identification at an early stage can be a helpful intervention in its own right. It should lead to:
1. the provision of information concerning safe drinking levels
2. a recommendation to cut down where indicated
3. simple support and advice concerning associated problems.
Such a brief intervention is effective in its own right. Successful alcohol misuse treatment involves motivational enhancement (motivational therapy), feedback, education about adverse effects of alcohol, and agreeing drinking goals. A motivational approach is based on five stages of change: precontemplation, contemplation, determination, action and maintenance. The therapist uses motivational interviewing and reflective listening to allow the patient to persuade himself along the five stages to change. This technique, cognitive behaviour therapy and 12-step facilitation (as used by Alcoholics Anonymous (AA)) have all been shown to reduce harmful drinking. With addictive drinking, self-help group therapy, which involves the long-term support by fellow members of the group (e.g. AA), is helpful in maintaining abstinence. Family and marital therapy involving both the alcohol misuser and spouse may also be helpful. Families of drinkers find meeting others in a similar situation helpful (Al-Anon).
ACUTE GENERAL Rx
• Observe for delirium tremens (DTs): if tachycardia or visual hallucinations occur, administer lorazepam or other benzodiazepines (Box 1-3).
• IM thiamine is mandatory in DTs and in acute extraocular disorders.
| Box 1-3. Management of Alcohol Withdrawal
Observe and normalize vital signs
Administer thiamine, 100 mg, then replace fluid and electrolytes
Sedate with chlordiazepoxide, 25 mg PO qid
Administer chlordiazepoxide, 25-50 mg IM prn for signs of withdrawal
Use haloperidol (1-2 mg PO q4h prn) or thorazine cautiously for hallucinations or agitation
Replace folic acid (1 mg/day PO) and thiamine (100 mg IM and then 100 mg/day PO)
Give multivitamin daily
Begin b-blocker (atenolol, 50 mg) or clonidine (0.2 mg PO bid) to reduce adrenergic signs
• Pharmacotherapies for alcoholism include the opiate antagonists (naltrexone 50 mg PO qd or nalmefene 10 to 40 mg qd), disulfiram, acamprosate, lithium, and SSRIs.
• To Alcoholics Anonymous or Adult Children of Alcoholics
• Family members to Al-Anon or Al-A-Teen
• Many cities have Salvation Army Adult Rehabilitation centers; all patients accepted, regardless of ability to pay
PEARLS & CONSIDERATIONS
The cure rate for alcoholism is very disappointing, regardless of the modality. Only those who want to be helped will be helped. An effective strategy for the primary care physician is a prominently displayed sign in the office that states, “If you think you consume too much alcoholic beverage, please discuss it with me.” Those who do open up the discussion can be given the facts in a nonjudgemental way and often can be helped. All too often, problem drinkers lie on the questionnaire until they face a life-threatening health issue-and even then denial often reigns supreme.